The adolescent and the medicine cabinet

Although the home should be a safe place, many families do not realize the potential danger hidden in their medicine cabinets. Every day in the United States, 670 adolescents initiate prescription opioid misuse.¹ According to the 2019 National Survey on Drug Use and Health, 16% of adolescents aged 12 to 17 years report past year prescription opioid use, and 2.3% report misuse.¹ Early opioid use has been associated with development of risky health behaviors, mental health disorders, use of other substances such as heroin, and future diagnosis of substance use disorder.^2-4 Unintentional or intentional overdose is also of concern: From 1999 to 2016, annual pediatric mortality from opioid poisonings increased 268%.⁵

Opioids pose a unique challenge because they are prescribed to treat pain, which varies from patient to patient, and may be prescribed in larger amounts than necessary post acute injury. Furthermore, families may not dispose of unused medications because of uncertainty about appropriate methods or desire to use prescriptions to treat future pain.⁶ The home environment has been shown to influence adolescent morbidity and mortality: Parent opioid use and family opioid prescriptions are respectively associated with adolescent opioid misuse and risk of overdose.^7,8 Half of adolescents report obtaining these medications from family members, and more than 20% of adults prescribed opioids report giving medications to others, suggesting appropriate management of both adolescent and family prescriptions is crucial.^7,9

In addition to the particularly concerning consequences of opioid misuse, many nonopioid medications commonly found in medicine cabinets may also pose harm to children and adolescents through acute ingestion. In 2019, the US Poison Control Centers received 177,068 calls regarding medication or toxin exposure in 13- to 19-year-olds.¹⁰ Implicated medications include nonopioid analgesics, antidepressants, antihistamines, stimulants, cardiovascular medications, and hypoglycemics. Compared with younger children, adolescents are more likely to have intentional exposures and experience adverse outcomes, including death, from ingestion of opioids or other medications.^10,11

Despite the clear potential risks of prescription substances, few families report receiving relevant guidance from health care providers about proper medication management and storage, and many families therefore lack knowledge to practice safe medication storage at home.^2,9 Research has shown that parental risk perception affects safe medication management, and there appears to be a common misconception that medications in the home do not pose a significant risk to adolescents.^12,13 Fortunately, studies have shown that anticipatory guidance on the hazards of prescription opioid misuse and appropriate medication management improves parental behaviors regarding safe storage.^14,15 Pediatricians can therefore have an important role in preventing adverse consequences of acute or chronic medication misuse.

Clear guidance from providers and families is particularly important for adolescents, who may be curious about or experiment with medication misuse. Parents can reduce risk by directly communicating expectations about substance use to their adolescents, including providing positive encouragement regarding abstinence, setting clear expectations, and defining reasonable consequences of violating trust. The Partnership to End Addiction has information on talking to children about medication misuse and parent strategies to prevent substance use.¹⁶ Families with controlled medications at home should take additional precautions. This includes locking up these medicines, counting pills, and educating adolescents about potential consequences of misuse. Families of adolescents with mental health concerns, particularly self-injurious behavior or suicidal ideation, may be advised to lock all medications out of sight.

Anticipatory guidance is also necessary when adolescents are prescribed medications. Safe medication management begins at the time of initial prescription with provider explanation of dosing, adverse effects, and duration of use. Providers should consider screening adolescents for substance use when prescribing controlled medications and emphasize the importance of never sharing medications: 16% to 29% of adolescents and young adults prescribed stimulants report being asked to divert their medication.^17,18

For adolescents with medical conditions requiring long-term medication use, families and providers should discuss a plan for developmentally appropriate transition from supervised medication use to adolescent independent use. This process should begin when the adolescent remembers to take the medication as prescribed, is able to name the medication and appropriate dose, and has shown independence in other areas (ie, completes homework without prompting).¹⁸ Caregivers should continue intermittent monitoring of medication administration with weekly pill dispensers or pill counting and remain vigilant for changes in adolescents’ functioning concerning possible signs of inappropriate use (poor grades or new conflicts at home).

Safe medication management also includes safe storage and disposal. The American Academy of Pediatrics, American College of Preventive Medicine, and the US Food and Drug Administration (FDA) recommend that families lock controlled medications out of sight, provide developmentally appropriate parental monitoring, and discard unused medications.²

Lastly, safe opioid management includes having the reversal medication naloxone available. If adolescents or families have opioids at home, they should be prescribed naloxone and educated in proper use. The National Institute on Drug Abuse and GetNaloxoneNow.org have information on obtaining and administering naloxone.^19,20

There are multiple resources for families regarding safe medication management. The FDA, Partnership to End Addiction, and American Association of Poison Control Centers have information on safe medication management.^16,21,22 The FDA has a searchable database of medicine takeback programs.²³

The Centers for Disease Control and Prevention also sponsors Up and Away, an education program for families on safe medication storage.²⁴ The Partnership to End Addiction sponsors a helpline for family concerned about a loved one’s substance use.¹⁶ Families should be advised to call Poison Control (1-800-222-1222) if they are concerned about accidental or intentional ingestion. For prescribers, Search and Rescue is an education campaign with resources and information to help reduce medication misuse.²⁵

The opioid epidemic and increase in related hospitalizations and overdose deaths have brought the importance of medication management at home into sharp focus. Although many prescription medications seem benign, misuse of the medicine cabinet can have significant consequences for adolescents. As trusted experts in children’s well-being, pediatricians should educate families on appropriate medication management to reduce the potential danger of the medicine cabinet and ensure a safe, healthy home.

References

1. Key substance use and mental health indicators in the United States: results from the 2019 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. Rockville, MD; 2020. https://www.samhsa.gov/data/

2. Engster SA, Bogen DL, Molina BSG. Adolescent and parent management of controlled prescription medications. Subst Use Misuse. 2019;54(14):2264-2274. doi:10.1080/10826084.2019.1645176

3. McCabe SE, Veliz PT, Boyd CJ, Schepis TS, McCabe VV, Schulenberg JE. A prospective study of nonmedical use of prescription opioids during adolescence and subsequent substance use disorder symptoms in early midlife. Drug Alcohol Depend. 2019;194:377-385. doi:10.1016/j.drugalcdep.2018.10.027

4. Kelley-Quon LI, Cho J, Strong DR, et al. Association of nonmedical prescription opioid use with subsequent heroin use initiation in adolescents. JAMA Pediatr. Published online July 8, 2019. doi:10.1001/jamapediatrics.2019.1750

5. Gaither JR, Shabanova V, Leventhal JM. US national trends in pediatric deaths from prescription and illicit opioids, 1999-2016. JAMA Netw Open. 2018;1(8):e186558. doi:10.1001/jamanetworkopen.2018.6558

6. Garbutt JM, Kulka K, Dodd S, Sterkel R, Plax K. Opioids in adolescents’ homes: prevalence, caregiver attitudes, and risk reduction opportunities. Acad Pediatr. 2019;19(1):103-108. doi:10.1016/j.acap.2018.06.012

7. Griesler PC, Hu MC, Wall MM, Kandel DB. Assessment of prescription opioid medical use and misuse among parents and their adolescent offspring in the US. JAMA Netw Open. 2021;4(1):e2031073. doi:10.1001/jamanetworkopen.2020.31073

8. Nguyen AP, Glanz JM, Narwaney KJ, Binswanger IA. Association of opioids prescribed to family members with opioid overdose among adolescents and young adults. JAMA Netw Open. 2020;3(3):e201018. doi:10.1001/jamanetworkopen.2020.1018

9. Kennedy-Hendricks A, Gielen A, McDonald E, McGinty EE, Shields W, Barry CL. Medication sharing, storage, and disposal practices for opioid medications among US adults. JAMA Intern Med. 2016;176(7):1027-1029. doi:10.1001/jamainternmed.2016.2543

10. Gummin DD, Mowry JB, Beuhler MC, et al. 2019 annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 37th annual report. Clin Toxicol (Phila). 2020;58(12):1360-1541. doi:10.1080/15563650.2020.1834219

11. Allen JD, Casavant MJ, Spiller HA, Chounthirath T, Hodges NL, Smith GA. Prescription opioid exposures among children and adolescents in the United States: 2000-2015. Pediatrics. 2017;139(4):e20163382. doi:10.1542/peds.2016-3382

12. Engster SA, Molina BSG, Bogen DL. Adolescent and parent knowledge, attitudes, and perceptions of harm of household controlled medications. Subst Use Misuse. 2020;55(5):734-742. doi:10.1080/10826084.2019.1701034

13. McDonald EM, Kennedy-Hendricks A, McGinty EE, Shields WC, Barry CL, Gielen AC. Safe storage of opioid pain relievers among adults living in households with children. Pediatrics. 2017;139(3):e20162161. doi:10.1542/peds.2016-2161

14. Voepel-Lewis T, Wagner D, Tait AR. Leftover prescription opioids after minor procedures: an unwitting source for accidental overdose in children. JAMA Pediatr. 2015;169(5):497-498. doi:10.1001/jamapediatrics.2014.3583

15. McCauley JL, Back SE, Brady KT. Pilot of a brief, web-based educational intervention targeting safe storage and disposal of prescription opioids. Addict Behav. 2013;38(6):2230-2235. doi:10.1016/j.addbeh.2013.01.019

16. Prevention & Early Action. Partnership to End Addiction. Accessed February 25, 2021. https://drugfree.org/prevention-and-taking-action-early/

17. Wilens TE, Adler LA, Adams J, et al. Misuse and diversion of stimulants prescribed for ADHD: A systematic review of the literature. J Am Acad Child Adolesc Psychiatry. 2008;47(1):21-31. doi:10.1097/chi.0b013e31815a56f1

18. Harstad E, Levy S; Committee on Substance Abuse. Attention-deficit/hyperactivity disorder and substance abuse. Pediatrics. 2014;134(1):e293-301. doi:10.1542/peds.2014-0992

19. Opioid Overdose Reversal with Naloxone. National Institute on Drug Abuse. February 20, 2020. Accessed February 27, 2021. https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-reversal-naloxone-narcan-evzio

20. GetNaloxoneNow. Accessed February 25, 2021. https://www.getnaloxonenow.org/#home

21. Where and how to dispose of unused medications. Food and Drug Administration. Updated September 10, 2020. Accessed February 21, 2021. https://www.fda.gov/consumers/consumer-updates/where-and-how-dispose-unused-medicines

22. Prevention. American Association of Poison Control Centers. Accessed February 26, 2021. https://aapcc.org/prevention

23. Controlled Substance Public Disposal Locations. U.S. Department of Justice Diversion Control Division. Accessed February 20, 2021. https://apps2.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e1s1

24. Up and Away. Centers for Disease Control and Prevention. Accessed February 20, 2021. https://www.upandaway.org/

25. Search and Rescue. Partnership to End Addiction. Accessed February 26, 2021. https://searchandrescueusa.org/